Background
Methods
Reimagining ask and act for the twenty-first century: project design and implementation
Participant recruitment
Program implementation
Data collection and analysis
Results
Family medicine practices | Practice type | Urban/ Rural | Non-physicians | Physicians | Patients | Youth patients (Age 13 – 24) |
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Practice 1 | FQHC | Rural | 34 | 10 | 14,789 | 2126 |
Practice 2 | FQHC | Suburban | 8 | 15 | 1119 | 104 |
Practice 3 | FQHC | Suburban | 89 | 5 | 14,244 | 2735 |
Practice 4 | FQHC | Urban | 10 | 31 | NR | NR |
Practice 5 | Group Practice | Suburban | 32 | 5 | 3559 | 453 |
Practice 6 | Group Practice | Rural | 40 | 3 | 13,537 | 1502 |
Practice 7 | Hospital/Health System | Rural | 6 | 1 | NR | NR |
Practice 8 | Hospital/Health System | Rural | 11 | 2 | 5975 | 570 |
Practice 9 | Hospital/Health System | Rural | 9 | 1 | NR | NR |
Practice 10 | Hospital/Health System | Suburban | 15 | 5 | 6607 | 1,130 |
Practice 11 | Hospital/Health System | Urban | 32 | 26 | 8599 | 1482 |
Practice 12 | Hospital/Health System | Rural | 14 | 5 | 4020 | 416 |
Practice 13 | Group Practice | Suburban | 2 | 3 | 1647 | 318 |
Practice 14 | Group Practice | Rural | 16 | 1 | 3670 | 628 |
Practice 15 | University-Owned | Rural | 29 | 11 | 7858 | 1281 |
Practice 16 | University-Owned | Urban | 21 | 28 | 5312 | 128 |
Practice 17 | University-Owned | Urban | 20 | 40 | 12,020 | 2000 |
Practice 18 | University-Owned | Rural | 24 | 34 | 15,421 | 2438 |
Leading change
Create a vision for change to establish buy-in from key stakeholders
The findings suggest that incorporating ENDS into an EHR is a multilayered problem and should be addressed at different levels. Currently, ENDS has not been included in many EHR systems and recommendations have been made to expand this [31]. This could be addressed directly by advocating for EHR vendors to include ENDS in routine builds. It also suggests that hospitals and health systems could request ENDS to be included in their EHR. But this may incur a cost and may require allocation of IT personnel, creating the need for buy-in from leadership and IT. Either way, a compelling vision is needed to create change.“Sometimes funding limits our ability to get access to certain [EHR] builds… just because it is not part of what the hospital would like… I think part of this project may be a need for increased advocacy in terms of getting [ENDS] embedded into more EHRs.”
Educate health care professionals to improve their confidence to address ENDS
Creating processes
Establish criteria for screening and quality improvement for ENDS cessation
Clinical recommendations do not provide much additional clarity, stating that interventions should begin with “school age children and adolescents,” but do not provide a specific age range [7, 17]. However, data from the National Youth Tobacco Survey suggests that screening for tobacco and ENDS use should, at minimum, begin by age 12, since 28 and 7% of 16–17 year old tobacco and ENDS users began using at or before age 12, respectively [38]. This is a substantial number, when also considering that earlier age of initiation is associated with stronger nicotine dependence throughout life [39].“I don’t get the impression that [health care professionals] understand how common [ENDS use] is among… middle school students. I think if [health care professionals] are making assumptions, they’re thinking high school and they’re surprised at the middle school age kids doing this.”
Patient characteristics | Standards of care |
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Youth: ≤ 12 to 17 years old | - Provide a confidential space for youth by asking parents/guardians to leave the room. Disclose positive screens only after getting permission from patients |
- Ask and document tobacco and ENDS use status | |
- If no, provide education to prevent tobacco and ENDS use | |
- If yes, use clinical judgement to determine how best to assist: | |
○ Behavioral counseling: The USPSTF found insufficient evidence to support behavioral counseling for tobacco and ENDS in youth, but the harms of behavioral counseling are likely to be small [40] | |
○ Pharmacotherapy: The USPSTF found no evidence supporting the use of medications to improve tobacco or ENDS cessation among youth [40] | |
Adults: 18 years old or older | - Ask and document tobacco and ENDS use status |
- If yes, advise them to stop, provide behavioral interventions and FDA approved pharmacotherapy [6] | |
Pregnant: 18 years old or older | - Ask and document tobacco and ENDS use status |
- If yes, advise them to stop and provide behavioral interventions [6] |
Be specific when asking about ENDS
Create EHR systems to support incorporating ENDS cessation
“Older EHRs don’t have the ability to make that integration or add questions… they are building whole new screens… whole new parts of their system. So it is more complicated. And there are some [EHRs] that don’t even have the ability to make those changes.”
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Health informatics companies should ensure that tobacco and ENDS are incorporated into their EHR systems in a way that integrates both as forms of tobacco, and that allows for easy documentation and reporting.
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Buy-in and support from IT personnel should be sought early in the absence of appropriate EHR set up. The vision for incorporating ENDS into tobacco cessation, as described earlier, may help IT personnel to understand why this important. A clear description of how to set up the EHR may help to ease the work needed by IT staff. Both could help support buy-in.
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EHRs should be set up to support screening, documentation, assistance, and reporting.
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Prompts should be used to facilitate screening and assistance. Research shows that prompts improve quality of care and some of the participants successfully used prompts to incorporate ENDS into tobacco cessation [43].
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Structured response fields (checkmarks, yes/no) should be used instead of unstructured fields (text entry) whenever possible to standardize screening, documentation, and allow for automated reporting.
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Multiple specific fields should be used to document the natural history for quitting tobacco and ENDS. Research shows that documentation in this manner is associated with more consistent screening and cessation assistance [44]. Some participants discussed successes adding structured response fields, saying: “we added a drop-down box within the vaping use section so that we can specify the device type, the frequency of use, … patient strengths, … reasons for vaping, …and past attempts at cessation.” Numerous fields for ENDs have been identified for use in documentation, including for: use (ENDS use, type of product used, frequency and amount used), treatment (advised to quit, counseling provided, referral to treatment or Quitline, medication prescribed, and patient education provided), and patient outcomes (willingness to quit, number of quit attempts, changes in ENDS use status) [44‐46].
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Use chart audits if EHRs cannot support incorporating ENDS into tobacco cessation
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Rapid cycle quality improvement cycles should take place at least every three months to support gradual but persistent improvement [48]. Suggested steps for using chart audits for quality improvement include: specifying the goal; identifying inclusion and exclusion criteria; defining the time period for review; stratifying by factors that may impact the trustworthiness of the results (clinic site for example), determine the sample size, and collect, organize, and analyze the data [49, 50].
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Use a sample rather than all patients. One participant manually reviewed every patient record for this project, but this type of review is too cumbersome to support long-term success and success at scale. Differences between performance and goals can typically be identified with a sample of 25 patients (range 5 to 280) with enough power for statistical significance [50]. A larger sample will be needed when differences between performance and goals are small.
Assign roles and responsibilities
Helping patients quit ENDS
Educate patients and their parents/caregivers about ENDS and potential harms
Avoid dual use and develop a plan to quit
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Identify the patient’s pattern of ENDS use.
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Establish a plan to quit tobacco and ENDS. Include a quit date.
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Educate individuals that use tobacco and ENDS that dual use is at least as harmful as conventional tobacco smoking and may be worse. Transition dual users off tobacco products.
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Transition ENDS users to FDA approved cessation aids as appropriate.
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Transition to full cessation over time.
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Provide services like counselling, classes, behavioral health, and quitlines to support cessation.
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Develop a system to follow-up with ENDS users to evaluate cessation progress.